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MARION COUNTY BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503).588-5147 <br /> Fax: (503) 588-7948 <br /> LAND USE COMPATIBILITY STATEMENT (LUCS) <br /> FOR ON-SITE SEWAGE SYSTEMS <br /> DATE: I a - I 11 MCBI File#: L� uG <br /> SECTION 1-APPLICANT INFORMATION <br /> 1. Property Address: 3 Atf Property ID#: <br /> Section: Township: Range: Tax Lot#: <br /> s <br /> 2. Name of Applicant: l4,feti j) lephone S#: 1y —i!d` 6 `l <br /> Mailing Address: ® $0/1' Z J i o _ "1- (1Q <br /> 3. Describe type of facility the on-site sewage system will serve(business,residence or other): <br /> 4 Single Family Residence <br /> ❑ Business <br /> ❑ Other: <br /> 4. Type of on-site sewage system permit application being proposed for this property: <br /> ❑ New Installation Permit <br /> Repair Permit <br /> ❑ Alteration Permit for: N(Replacement Dwelling ❑ Bedroom(s)addition <br /> ❑ Other changes in land use involving potential sewage flow increase: <br /> G:\FORMS\SEPTIC\Application Packets\S-39 LUCS.doc MC: S-39 rev: 8/10,04/12, 03/18 <br />